Apply for Residency

Application Process

1 . Complete online application below and submit the form.

2. Complete interview with House Manager.

3. If accepted, arrange time & date of arrival.

Contact Us:
Phone:1-866-245-1497
Email: [email protected]

Resident Name

Resident Phone Number

Resident Date of Birth

Gender

Sobriety Date

Emergency Contact

Emergency Contact Phone Number

Drug(s) of Choice

List of Current Medication

Medical Conditions

Are you involved in legal action or drug court? If so, what county?

Have you been convicted of arson?

Are you a registered sex offender?

Source of Income

Payee Name & Relation (Person paying rent dues)

Payee Phone Number

Requested Move In Date

Currently in treatment?

If yes, please provide the name of the treatment center, your counselors name, and contact phone number.